Week 5 - G - Renal transplantation

Question 1

What is the treatment of choice for end stage renal failure?

Answer 1

This would be a renal transplant

Question 2

What is the classification of end stage renal failure?

Answer 2

GFR<15 or patient on renal replacement therapy

Question 3

When was the first renal transplant?

Answer 3

In 1954 between monozygotic twins - The Herrick twins

Question 4

The blood types and the HLA (human leuocyte antigen) need to match in order for a successful transplant What are the four blood groups? Which can donate to all blood groups but can only recieve blood from others with the same blood type?

Answer 4

O, A, B, AB O - can give to any blood group but can only receive blood form itself

Question 5

HLA are cell surface proteins expressed on cells. These activate the immune system if non self and cause rejection What are the three main important HLA in transplant?

Answer 5

HLA A HLA B HLA DR

Question 6

Why are HLA so important in their role in transplant?

Answer 6

If patients have preformed antibodies against their graft, this may lead to graft rejection Matching HLA improves the chances of transplant survival

Question 7

Which type of Tcell promotes the formation of B cells to produce antibodies against the graft?

Answer 7

CD4 Tcells

Question 8

What are the three main types of host transplant rejection? What is the time period for each time of rejection to occur?

Answer 8

Hyperacute rejection (minutes to hours) Acute graft failure ( 6 months)

Question 9

What happens in hyperacute hypersensitivity?

Answer 9

due to pre-existing antibodies against ABO or HLA antigens

Question 10

What happens in acute hypersensitivity? How is it treated?

Answer 10

Acute usually happens within 6 months due to mismatched HLA. Cell-mediated (cytotoxic T cells) Treat with methylprednisolone and increase immunosuppresion

Question 11

What happens in chronic transplant rejection?

Answer 11

Both antibody and cell mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)

Question 12

What type of hypersensitivity is graft transplant rejection?

Answer 12

It is a type IV hypersensitivity reaction as there is a donor Tcell mediated attack against foreign recipient HLA (MHC)

Question 13

o Suppression of the B cells, T helper cells, cytokines and complement in order to reduce chance of transplant rejection When after the transplant is the patient most heavily suppressed?

Answer 13

The patient is most heavily suppressed for the months after the transplant

Question 14

Most patinets after a kidney transplant are on a triple therapy regime What does the triple therapy regime include?

Answer 14

A calcineurin inhibitor, a antimetabolite/blocks purine synthesis and prednisolone

Question 15

What are the two options of calcineurin inhibtor that can be used in a renal transplant patinet?

Answer 15

Tacrolimus or ciclopsorin (CSA - ciclosporin A)

Question 16

How do the two calcineurin inhibtors work?

Answer 16

They inhibit the activation of Thelper cells by cytochrome p450

Question 17

What are the two calcineurin inhibitors, what is their mechanism and what are their side effects?

Answer 17

Ciclosporin and tacrolimus They inhibit the activation of Tcells by cytochrome p450 Side effects-Renal Dysfunction, Hypertension, Diabetes, Tremors

Question 18

What are two antibmetabolites that work by blocing purine synthesis?

Answer 18

This is azathioprine and mycophenalate

Question 19

What does the blocking of the purine synthesis cause?

Answer 19

Leads to suppression of proliferation of lymphocytes and B cells

Question 20

What are the side effects of azathioprine and mycophenolate?

Answer 20

They can cause leucopaenia, anaemia and GI upset

Question 21

Run through What are the two antibemtabolites? How do they work? What are there side effects?

Answer 21

Azathioprine and mycophenolate They work by blocking purine synthesis leading to increased suppression of lymphocytes and Bcells They can cause leucopaenia, anaemia and GI upset

Question 22

What drug should azothioprine not be used in combination with and therefore mycophenolate would definitely be the antimetabolite chosen?

Answer 22

Do not used in combination with allopurinol - treatment of long term/recurrent gout

Question 23

Steroids act non selectively to suppress activity of T cells and proliferation of B cells. Which steroid is used? Name some side effects of steroids?

Answer 23

Use prednisolone Osteoporosis Weight gain Diabetes and infection Easy bruising/thinning of the skin

Question 24

There are 3 types of donor Name them

Answer 24

Deceased brain dead Deceased cardiac dead Living donor

Question 25

Which donor grafts have the best outcome?

Answer 25

Living donor grafts - planned surgery and minimal ischaemic time

Question 26

How are deceased brain dead donor grafts better than deceased caridac dead in terms of graft function?

Answer 26

Deceased brain dead is where the kidneys are removed at the same time as other organs, whereas deceased cardiac dead, the organ could necrosed due to being non perfused for too long

Question 27

What must all living organ donors undergo?

Answer 27

Must undergo psychological assessment to ensure they understand the risks they are undertaking

Question 28

Which patients are suitable for kidney pancreas dual transplants?

Answer 28

A kidney-pancreas transplant is an operation to place both a kidney and a pancreas — at the same time — into someone who has kidney failure related to type 1 diabetes. Transplant pancreas as it is not functioning to make enough insulin Replaces kidney function and pancreatic Islet cell function.

Question 29

Patients have to be suitable to undergo transplantation How long should the patient be hoping to live after the transplant

Answer 29

Greater than five years life expectancy

Question 30

What are absolute contraindications for renal transplant?

Answer 30

active infection, cancer (or recent cancer (<5 years), severe co-morbidity (severe COPD, heart failure)

Question 31

How does the surgery usually take place?

Answer 31

Extraperitoneal procedure Usually 3-4 Hours Stent inserted between ureter and bladder Wound 15-20 cm long

Question 32

What type of scar is left on the patient after the surgery?

Answer 32

Patinet usually has a hockey stick scar

Question 33

What are complications that can occur from the surgery?

Answer 33

Thrombosis Infection Ureteric Stricture and hydronephrosis

Question 34

If suspecting graft rejection, what is taken to confirm this?

Answer 34

A renal biopsy

Question 35

Delayed graft function affectes 40% of patients, what can it cause?

Answer 35

Acute tubular necrosis - need to treat with haemodialysis to keep kidney working before allowing the transplant to work on its own

Question 36

If transplant fails, what happens?

Answer 36

Patinet goes back onto dialysis and another transplant if they are viable